Clinical Review definition

Clinical Review means a process in which information about the Covered Person is collected and reviewed against established criteria to determine if the service, treatment or supply is Medically Necessary and is a Covered Health Service.

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Clinical Review means an on-site periodic evaluation by an ACC Clinical Reviewer of the Suppliers service delivery against this service specification;

Clinical Review. A clinical review is conducted by clinical representatives from a hospital and DMH clinical staff who are delegated by the DMH Commissioner to serve this function and review any materials submitted relevant to the decision. Delegated staff may issue a decision or request additional information from persons with knowledge of the issues prior to making a decision. The DMH Medical Director will render a determination regarding authorizing or denying the payment. If the DMH Medical Director believes additional consultation is needed to render a determination he may 1) informally consult with another psychiatrist, who has no vested interest in the determination, regarding medical/clinical necessity and the clinical review process or consult with the Department of Vermont Health Access Medical Director prior to making a determination.

Examples of Clinical Review in a sentence

• A Post-Service Medical Necessity Review may be performed when a Prior Authorization or Recommended Clinical Review was not obtained prior to services being rendered.

• The Recommended Clinical Review process may require additional documentation from the Member’s health care provider or pharmacist.

• Submitted services (subject to Medical Necessity review) not included as part of Recommended Clinical Review may be reviewed retrospectively.

• To determine if a Recommended Clinical Review is available for a specific service, visit the Blue Cross and Blue Shield of Montana website at ▇▇▇.▇▇▇▇▇▇.▇▇▇/▇▇▇▇-▇▇▇▇/▇▇▇▇▇-▇▇▇-▇▇-▇▇▇▇▇▇▇/▇▇▇▇▇▇▇▇▇▇▇-▇▇▇▇▇▇▇▇▇▇.▇▇▇ for the required Prior Authorization and Recommended Clinical Review list, which is updated when new services are added or when services are removed, or call Customer Service at the number on the back of the Member’s identification card.

• Once a decision has been made on the services reviewed as part of the Recommended Clinical Review process, the services will not be reviewed for Medical Necessity again on a retrospective basis.

• The Member or provider may request a Recommended Clinical Review.

• The Plan will review a Clinical Review request to determine if it meets approved Blue Cross and Blue Shield of Montana Medical Policy and/or level of care review criteria for medical and behavioral health services.

• Contacting Behavioral Health‌ The Member, the Member’s provider, or authorized representative may contact The Plan for a Prior Authorization or Recommended Clinical Review by calling the toll-free number shown on the back of the Member’s identification card and follow the prompts to the behavioral health unit.

• Recommended Clinical Review‌ A Recommended Clinical Review is a Medical Necessity review for a covered service that occurs before services are completed and helps limit the situations where the Member may have to pay for a non-approved service.

• There is an option for Your Provider to request a Recommended Clinical Review to determine if the service meets approved HMO medical policy and/or level of care review criteria before services are provided to You.

More Definitions of Clinical Review

Clinical Review means any review performed by the Serve You Rx clinical staff. Clinical Reviews include clinical prior authorizations. Clinical Reviews may also include other hard-halt point of service edits such as standard prior authorization reviews, step therapy reviews, high dollar claim reviews, and other cases that necessitate clinical staff review. Serve You Rx will perform standard prior authorization, clinical prior authorization, and other Clinical Reviews pursuant to criteria adopted by Plan Sponsor as part of the Benefit Plan Implementation Guide. Any criteria for coverage that Plan Sponsor desires to be applied to the Benefit Plan’s Claims that is different from Serve You Rx standard criteria must be supplied to Serve You Rx in advance prior to implementation. Additional charges may apply to customized administration. Serve You Rx makes no warranty or representation that Serve You Rx criteria for coverage is consistent with criteria applied by a secondary or subsequent payer.